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This individual participates in the Jackson Hospital Utilization Management Committee by providing analysis of utilization- and medical necessity-related denials. This individual will report to the Director, Case Management and will collaborate closely with leadership and staff within and outside of the case management, utilization management & revenue cycle teams for the purpose of improving clinical, operational, and financial outcomes.
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Training Required •California OSHPD Experience •State and/or Regulatory Agencies coordination related to Healthcare Construction Experience Training Preferred/Desired •Lean Process Improvement •Change Management •Design for Patient Focused Care •Evidence Based Design •RCDD •Sustainability.
$49.2 - $71.34 an hourFull-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Conduct utilization review, incident management and review and quality assurance reviews. The Clinical Supervisor is responsible for maintaining OASAS regulatory compliance and assuring that programs operate in accordance with VIP Community Services organizational standards.
$70,000 - $75,000 a yearFull-timeExpandApply NowActive JobUpdated 6 days ago - UpvoteDownvoteShare Job
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Foreign Medical Graduate; and, two (2) years of medical records review or utilization and case management experience; or. Clinical Document Specialist (CDIS): under the supervision of the leadership of the Director of Health Information Management or designee is responsible to review medical records for appropriate documentation that will assist to enhance appropriate documentation that will enhance reimbursement, and improve documentation in order to be in-compliance with regulatory agencies and reduce denials.
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Helps to develop and support implementation of a project management office (PMO) with tools such as project portfolio management to prioritize projects to deliver improved business performance and increase utilization and skills of plant team members.
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The Director ensures staff compliance with organizational policies and external regulatory agencies and takes leadership responsibility to coordinate the integration of the department's patient care and discharge planning processes with related hospital departments and external agencies to ensure continuity of care and optimal clinical resource utilization.
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If acting in the capacity as a clinical pharmacist the incumbent may also review UM requests; provide consultation into the case and disease management identification process, and consult with the Organization's Associate Medical Directors and Medical Directors when appropriate, follow-up on appeals in accordance with our regulatory guidelines.
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Performs overall utilization management, resource management, discharge planning and post-acute care referrals and authorizations. Attends Department meetings and Corporate Care Management Training sessions in order to maintain current knowledge of all payer and regulatory requirements, UPMC CM policies and procedures, community resources.
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Knowledge of utilization review and quality assurance procedures, as well as experience with InterQual or Milliman and Case Management procedures of medical necessity auditing. In addition to the clinical expertise needed for the medical necessity reviews, the incumbent will perform scheduled and unscheduled regulatory and payment integrity audits, develop and standardize policies and procedures, training and education, compliance investigations, and reporting to ensure compliance with University, State, and Federal guidelines.
Full-timeExpandApply NowActive JobUpdated 16 days ago - UpvoteDownvoteShare Job
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Proficiency in computer programs / software such as Microsoft Word, Outlook, Excel, Power Point, Power BI, SAP (Recipe Management), Net Weight and Consumer ComplaintsWorking knowledge of regulatory and quality system requirements – PEP, HACCP, Good Manufacturing Process (GMP), etc.
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Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families.
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This position is an employee of CPS Solutions, LLC.Responsibilities Include:Develop policies and procedures in the areas of procurement, inventory control, receiving and storage, distribution, duplicating and mail transport throughout the hospitalProvide administrative support to the Chief Operating Officer in the form of reports, budgets, supply utilization analysis and capital expenditure management.
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The Clinical Quality Program Manager adheres to WellSky's Utilization Management Program Description and Quality Improvement Program requirements and serves as a clinical subject matter expert on relevant regulatory state and federal requirements under the Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and other relevant governing bodies.
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Certifications Required - Registered Nurse in the state of Louisiana Certification as a Case Manager (CCM) required within 2 years of hire Other Required - Three years experience in managed care, utilization or quality management, regulatory compliance, medical management or other related MCO departments/functions with BSN Knowledge Skills and Abilities (KSAs) Must have computer skills and dexterity required for data entry and retrieval of patient information.
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The Vice President’s responsibilities include leadership direction for all Medical Management Department employees as well as setting the direction and scope of all activities related to Referral Management, Inpatient Case Management, Ambulatory Case Management, Disease Management, ACO, Regulatory Compliance and Quality Management.
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